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Questions 158

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Question 1 of 5

The client with chronic renal failure is prescribed aluminum hydroxide (Amphojel). The purpose of this medication is to:

Correct Answer: A

Rationale: Aluminum hydroxide binds dietary phosphate in the gut, reducing serum phosphate levels in chronic renal failure, where kidneys cannot excrete phosphate. It does not affect urine output, ulcers, or bowel elimination directly.

Question 2 of 5

A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?

Correct Answer: A

Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.

Question 3 of 5

Which situation would be reportable to the state board of nursing?

Correct Answer: B

Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.

Question 4 of 5

A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

Correct Answer: B

Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.

Question 5 of 5

A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is:

Correct Answer: D

Rationale: Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.

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